Images of ambulances backed up outside hospitals, patients lying in corridors, and burnt-out staff are now familiar sights. The collapse in A&E performance – measured by how quickly people are seen and then, if necessary, admitted – appears to show there is something going very wrong in emergency departments. In actual fact, A&E isn’t the problem at all.

The perfectly logical assumption is that either too many people are showing up, or there are too few staff to deal with the workload, or both. That, after all, is what causes queues.

Yet when you actually look at what has happened to demand, the number of people showing up at A&E is basically the same as before the pandemic, when performance was far better. Nor does it look like those patients are sicker: the percentage of patients admitted to a hospital ward after presenting at A&E – i.e. those needing further treatment – is actually lower than in 2019.

And while there is no doubt that being an A&E doctor is one of the toughest jobs in medicine, there’s no shortage of them. The number of emergency medicine doctors is almost double that of 2010, while attendances have increased by just 24%.

All of which tells us that the problem lies outside emergency departments. The real challenge is moving patients through hospital wards once they’ve left A&E.

Once patients are admitted to the rest of the hospital they need a bed, a medical team to be in place to treat them, and a clear plan to get them home when they’re deemed fit to leave. Blockages and inefficiencies in this process are creating a bottleneck which means patients can’t be moved out of A&E.

In our new Reform analysis we look at beds, staff and discharge to identify the likely drivers of the current crisis. It’s long been recognised that England has fewer hospital beds than many other wealthy countries, and our bed occupancy rate is higher than recommended. But while A&E performance has cratered, the bed occupancy rate hasn’t changed much in the last few years. So, while more beds would help tackle the elective care backlogs, bed capacity has not driven the ballooning A&E wait times.

Barely a day goes by without calls for more hospital doctors and nurses, with the implication being that shortages are driving poor performance. Yet we currently have record numbers of both.

Which leaves us with the discharge process. Patients are waiting record lengths of time in hospital even after they have been declared fit to go home.

It’s tempting to say that the reason for this lies outside of the NHS’s control, and more specifically to blame the social care crisis. And this is indeed a key cause – shortages in the availability of domiciliary and residential social care mean patients are trapped in hospital. But that’s only part of the story.

Examining the latest data on those patients who have been in hospital for over 21 days but are fit to leave, we found that more than 40 per cent of delays relate to issues that are the NHS’s responsibility. If we want to get on top of our system crisis, we need to work out what to do about these.

One way to improve this situation is through boosting management capacity. Contrary to popular belief, hospitals are under-managed. From properly understanding bed availability, to deploying staff, organising discharge processes to arranging ongoing care outside of hospital, good operational management is essential.

So too is ensuring that NHS community and rehab staff are available to enable discharge. While hospital staff numbers have increased significantly over the past decade, this type of care has not been prioritised. The majority of those well-reported NHS vacancies are in the services that keep patients out of hospital in the first place and get them home quickly when necessary.

If we want to fix the A&E crisis, we have to properly understand what is driving it. The data clearly shows that investing in good operational management and investing in staff outside the hospital would be good places to start.

Sebastian Rees is a senior researcher at the public services think tank Reform.

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